Registration Form
The Summitry Coaching Program
Please complete registration information below. Check appropriate program for which you wish to register, payment option, and amount enclosed. As appropriate, either enclose check or money order or complete credit card information. For check or money order, mail to: Summitry Coaching c/o PSP, P.O. Box 6713, Vacaville, CA 95696 USA. For credit card order, either mail to above address, fax to + 916-641-8971, or e-mail to triciaerck@yahoo.com.
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First Name: _________________________ Family/Surname:_________________________
Title (Optional): ______________________
Organization (Optional): _____________________________
Mailing Address: ___________________________________________________________________________
City: ________________________ State/Province: ______ Postal Code: __________
Country: ___________
E-Mail Address: ____________________________________
Telephone Number: _______________________
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Program for which You Wish to Register:
_____Washington D.C.- TBD
_____Chicago (Illinois)- TBD
_____Harpswell (Maine)- TBD
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Payment Option
_________ Option One: $5000 (Total) [$5000 due at registration]
_________ Option Two: $5,500 (Total) [$3000 due at registration/$2500 due at 2nd Workshop]
_________ Option Three: $6000 (Total) [$2000 due at registration/$2000 due at 2nd Workshop/$2000 due at 3rd Workshop]
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Payment Method
(Please make payment in U.S. dollars to “The Professional School of Psychology”)
____Check
Check Number: ________________ Amount: US$ __________________
___________Credit Card ______________Visa ___________MasterCard
Check appropriate card type
Card Number: ______________________________________
Expiration Date(mm/yy): ____________
Signature: __________________________________
Name on Card: ________________________________
